Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider using teriparatide beyond a cumulative maximum of two years now that the black box warning regarding osteosarcoma has been removed?
This is a very good question. Early studies with PTH compounds for osteoporosis showed you could give it for three years and still have an effect on increasing bone mass. The black box warning was for osteosarcomas that occur in young adults and children, and the black box warning was also for indiv...
How do you approach immunosuppression targeting skin thickening in scleroderma after the initial three years of onset?
I think there is still a role for trial of immunosuppression in the case of a patient who has diffuse skin disease and has signs of progression or lack of improvement even if it is beyond 3 years. If a patient has limited skin distribution (i.e., only sclerodactyly) or the skin has not changed over ...
How do you counsel patients on JAK inhibitors about the risk of venous thromboembolism, MACE, and cancer?
I advise patients that there remain many unanswered questions regarding these side effects that will be resolved with longer term use with these agents. Shared decision-making is critical for these discussions. Data available from current extensions of clinical trials for JAKi, additional risk facto...
What therapies have you had the most success with for calcinosis cutis in dermatomyositis patients?
Treatment of calcinosis cutis is difficult with therapy aimed at the underlying condition. Many of the treatments that have been tried in the literature have been reported in small case reports/series and have had variable success rates. I have tried diltiazem (limited by lightheadedness and fatigue...
When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?
The answer to this question is not straightforward mainly because there are limited data in this area. Hydroxychloroquine and Chloroquine directly affect cardiac repolarization and are associated with QT prolongation. Given this, there is an argument for getting a baseline ECG for patients initiatin...
Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?
The SENSCIS trial randomized patients with SSc associated ILD to Nintedanib or placebo. I think about half of these patients were still taking MMF. There was no negative signal in the group on MMF and Nintedanib, they fared at least as well as those who got Nintedanib alone and both did better than ...
What is your approach to a patient with an isolated positive rheumatoid factor, negative anti-CCP antibody, and no clinical or imaging evidence of rheumatoid arthritis?
In our clinic, we screen for hepatitis C infection in all patients with polyarthralgias especially if the RA factor is positive. A positive RA factor is non-specific and can be present in a number of chronic inflammatory conditions, autoimmune and otherwise, including alcoholic liver cirrhosis, hepa...
How do you approach the treatment of inflammatory polyarthritis in patients with myelodysplastic syndromes?
The diagnosis of a myelodysplastic syndrome (MDS) can severely limit our therapeutic choices in managing an accompanying inflammatory arthritis. Many hematologists are concerned about the possible disruption of the cytokine milieu in MDS that the addition of a biological drug may induce, and for thi...
Are there features of a nerve biopsy that help distinguish late nerve damage from vasculitis versus from a demyelinating disease?
Chronic demyelinating processes can have features of demyelination on nerve biopsy including thinly myelinated fibers, remyelinating fibers, onion bulb formation, myelinated fiber loss, and axonal regeneration, as well as variable degree of inflammation. Late vasculitic neuropathy would show axonal ...
Do you check pertussis serologies when sending labs for antiphospholipid syndrome?
The short answer is no. I do not check pertussis antibodies when evaluating patients for anti-phospholipid syndrome. A slightly longer answer is still no and, for example, a review published in the Annals of Rheumatic Diseases by Ron Asherson in 2003 discussing the relationship between various infec...